Issue
20
Human Development Department, Japan International Cooperation
Agency
Global Promotion of Maternal and Child Health Handbook
Technical Brief Aug 2017
UNRWA and MCH Handbook for Palestine refugee mothers
The United Nations Relief and Works Agency for Palestine
Refugees in the Near East (UNRWA) was established in 1950,
following the 1948 Arab-Israeli War. It has been providing primary
health care services to growing 5.4 million Palestine refugees at
143 health centers across five fields of operation (Jordan, West
Bank, Gaza, Lebanon and Syria). These health services have been
utilized by approximately two thirds of UNRWA registered refugees.
Although an increasing number of refugees seek services for
non-communicable diseases and mental health at UNRWA health
centers, pregnant women, mothers, and children account for the
greatest proportion of health service users.
UNRWA’s Maternal and Child Health Handbook (MCH Handbook) was
introduced in Palestine, and was the first of its kind to be
produced in Arabic. It began as a national project for Palestine
with technical and financial support from JICA, and with many local
stakeholders involved, including UNRWA. The MCH Handbook was
distributed to all pregnant women and mothers with child/children
under five years of age in the West Bank and Gaza in 2008.
Following highly successful uptake in the Palestine field, its
implementation has been scaled up so as to include Palestine
refugees in Jordan, Lebanon
and Syria in 2010, with the current version of the handbook in
use since 2014. Today, the MCH Handbook is provided to over 100,000
mothers in UNRWA’s five fields of operation each year.
e-MCH Handbook initiative at UNRWA health centers in Jordan
The prevalence of mobile-phones has been increasing around the
world, allowing more opportunities for the implementation of
mobile-phone-based health interventions (mHealth). The mobile
technologies have increased the potential for self-management of
health conditions, treatment adherence, and communication between
health workers and patients. Moreover, they have been acclaimed for
its cost-effectiveness.
In April 2017, JICA and UNRWA jointly launched a smart-phone
software application of the MCH Handbook (e-MCH Handbook) in
Jordan, as a tool for increasing both the continuum of care and
access to maternal and child health services. This was supported by
two technology platforms: Jordan’s high smartphone coverage (51% as
of 2016) and UNRWA’s electronic medical records system, which is
connected to the e-MCH Handbook. The e-MCH Handbook would also send
its users reminders of appointment times, provide health education
information, and function as a more efficient communication tool
between patients and UNRWA health centers than the traditional
paper-based MCH Handbook.
Evaluation of e-MCH Handbook dissemination and implementation
status
Studies on operational realities and outcomes in dissemination
and utilization of mHealth interventions are l imited to date. To
bet ter understand the dissemination and utilization of e-MCH
Handbook among Palestine refugees in Jordan, a mixed-method study
using sequential exp lorator y design was conducted three months
after its introduction. Four focus group discussions (FGDs) were
conducted among the total of 22 pregnant women and mothers
▲ Figure 1. Features of the e-MCH Handbook
JORDAN: UNRWA's electric MCH Handbook application for Palestine
Refugees
Maternal and Child Health Handbook,UNRWA, 2014
Health center A(N=149)
Health center B(N=257)
Age (year) [mean± SD] 28.5 ± 7.4 28.2 ± 5.5
Spouse age (year) [mean ± SD] 34.3 ± 8.3 34.7 ± 6.7
Age at first birth (year) [mean ± SD] 21.3 ± 4.0 22.2 ± 3.9
Mobile phone coverage Yes 135 (90.6%) 243 (94.6%)
No 10 (6.7%) 10 (3.9%)
Smartphone coverage Yes 127 (85.2%) 222 (86.4%)
No 13 (8.7%) 24 (9.3%)
Know about e-MCH Handbook
Yes 69 (46.3%) 99 (38.5%)
No 63 (42.3%) 139 (54.1%)
Have downloaded e-MCH Handbook
Yes 26 (17.4%) 27 (10.5%)
No 37 (24.8%) 68 (26.5%)
Have used e-MCH Handbook Yes 18 (12.1%) 14 (5.4%)
No 7 (4.7%) 13 (5.1%)
Frequency of use Very often 0 (0.0%) 7 (2.7%)
Sometimes 27 (18.1%) 14 (5.4%)
Rarely 34 (22.8%) 37 (14.4%)
ⓒ Japan International Cooperation Agency5-25, Niban-cho,
Chiyoda-ku, Tokyo, Japan; Email: [email protected]
with children under five years of age at four dif ferent UNRWA
health centers. Qualitative data from these FGDs were then analyzed
and used to supplement the development of questionnaires that
assessed attitudes towards mobile technology and the e-MCH Handbook
specifically. Self-administered questionnaires were distr ibuted to
a total of 406 mothers attending 10 UNRWA health centers in Jordan.
Due to limited data availability at the time this Technical Brief
was written, only the findings from two health centers are included
in the analyses.
FGDs identified attitude of pregnant women and mothers towards
the e-MCH Handbook. Key findings were that most had smartphones,
but felt the e-MCH Handbook was unfamiliar and difficult to
navigate and preferred the paper-based MCH Handbook over the e-MCH
Handbook. Our study confirmed that the dissemination and
utilization of the e-MCH Handbook among Palestine refugees has been
limited (Table 1). Less than half of the mothers knew about the
e-MCH Handbook (46.3% and 36.5% in health centers A and B,
respectively), and very few downloaded the application (17.4% and
10.7%) and used it (12.1% and 5.4%).
Opportunities for e-MCH Handbook and importance of evidence
reporting
The MCH Handbook has become essential for the continuum of care
among Palestine refugee mothers and children. Our data underscore
the
importance of better dissemination approaches for mHealth
interventions. Benefits of the e-MCH Handbook should be more
strategically shared with mothers. Its utilization should be
facilitated through advertising campaigns, greater
user-friendliness of the application, easy acquisition of the
application, sufficient staff training, and considerations to
social and cultural attitudes towards mobile technology and the
Internet. With proper monitoring and evaluation, we would be able
to ensure that the e-MCH Handbook application is available among
those in need. if being successfully disseminated, the e-MCH
Handbook will provide Palestine refugees not only with the benefits
equivalent to the paper-based MCH Handbook, but also with those
unique to mHealth.
mHealth is just a newly developed field of health, but holds
tremendous potentials to facilitate and improve MCH status. It is
increasingly important for MCH professionals to report on evidence
suppor ting mobile interventions, which has led to the introduction
of the new guidelines for mHealth interventions in 2016 by WHO
technical group (mHealth Evaluation, Reporting and Assessment
(mERA) checklist). In our study, further analysis will be conducted
to examine the factors associated with knowledge and usage of the
e-MCH Handbook, illustrating content, context, and technical
features of the e-MCH Handbook, as suggested in the mERA checklist.
Future studies should be conducted to determine if similar trends
in the adoption of the e-MCH Handbook exist in other communities,
and if a generalizable set of conditions for the dissemination and
implementation of the e-MCH Handbook can be developed.
Akiko Kitamura, Ryunosuke Goto, Seif Nasir, Majed Hababeh, Ghada
Ballout, Akihiro Seita
United Nations Relief and Works Agency for Palestine Refugees in
the Near East, Amman
Palestine refugee mother accessing the e-MCH Handbook
▼ Table 1. Characteristics of sampled pregnant women and mothers
having received e-MCH Handbook and their utiliazation status as of
August 2017
Further readings
1. UNRWA. UNRWA Health Department annual report 2017. Amman:
UNRWA (in press).
2. Agarwal S, et al. Guidelines for reporting of health
interventions using mobile phones: mobile health (mHealth) evidence
reporting and assessment (mERA) checklist. BMJ 2016; 352:
i1174.
3. Wesley H, et al. No health without peace: why SDG 16 is
essential for health. Lancet 2016; 10058: 2352-3.
*Denominator is the total sample size of each health center